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When is head pain more than just a headache in children?


Of all the memories that linger from my childhood, the most vivid are those that correlate with a migraine headache. Vomiting in the school bathroom. Lectured by a well-intentioned but ignorant principal to suck it up and play through the pain. Resting my aching head on the cold tile floor of my second-grade classroom as I wait for my mother to pick me up from school. Leaving a friend’s slumber party early, in tears.

You’d think that after 40 years of migraines I’d be an expert in diagnosing the illness in others. But when my own son began complaining of headaches a couple of years ago at age 5, I didn’t know how to address it. All he could tell me was that his head hurt. He wasn’t sobbing or vomiting, as I did as a child, so I wasn’t sure of the best plan of action. Was he in the throes of a migraine attack?

According to the American Academy of Pediatrics, “Any child can get a migraine. About 10 percent of children age 5 to 15 and up to 28 percent of teens get them.”

The odds increase if there is a family history of the affliction. The American Migraine Foundation says that if one or both parents suffer from migraine, there is a 50 to 75 percent chance that the child will inherit it.

But what makes migraine so challenging, particularly in children, is that migraineurs can experience symptoms differently. One child might have visual disturbances before a headache, while another might feel only pain in the stomach, with no head pain at all. These variations make it all the harder for parents to know the severity of the situation.

Even with my own history — first migraine at age 4, first medication prescribed by a neurologist at 12 and a family history of migraine on my mother’s side — I can’t say definitively that my son is suffering from migraine during one of his headaches.

When a child can’t adequately describe what they’re feeling, it’s difficult for parents to know if the headache is indicative of a more serious condition. When is stomach pain really a sign of migraine? At what point should the child’s pediatrician be consulted? Should the child see a neurologist?

John Gaitanis, chief of pediatric neurology at Floating Hospital for Children at Tufts Medical Center, says that typically, migraine in children starts small and can be preceded by an aura — a sensory disturbance that can include flashing lights, black spots or colors — and nausea. Then a headache builds in intensity until it plateaus out and lingers for anywhere from 90 minutes to four hours, with two hours being the average.

“If you have all those features, then it’s overwhelmingly likely it’s migraine,” Gaitanis says. “But when you start to take away some of those features, then your probability changes a little bit, so you have to explore all different headache options.”

To further complicate the issue, younger children between the ages of 5 and 9 can exhibit subtypes of migraine. One, called abdominal migraine, affects the stomach but not the head, and according to the American Migraine Foundation “consists of episodes of abdominal pain that may be accompanied by nausea, vomiting, loss of appetite or loss of facial color.” The pain is typically in the middle of the abdomen around the bellybutton and can last from two hours to three days.

The other, cyclic vomiting syndrome, is defined by the Mayo Clinic as episodes of severe vomiting, with no apparent cause, that can last for days. Often, children who suffer from either condition begin to get the more familiar migraine head pain once they enter their teens.

With such a wide array of symptoms, parents might not know when to seek medical help. Elizabeth Leleszi, medical director of the Beaumont Children’s Headache Center, says they should pay attention to their instincts.

“The first rule of pediatrics, I learned long ago, is that the parents are 99.99 percent right,” Leleszi says. “So, if something is just not right, bringing that to the attention of the pediatrician, family practitioner or their primary care provider is very important.”

Parents can then work with their child’s doctor to identify triggers that could bring about a migraine attack.

“Any lifestyle changes that might be able to ameliorate the frequency or the intensity of migraine is important to establish,” Gaitanis says. “We start with that before we rush right to medications.”

Common triggers include sleep deprivation or changes, anxiety, stress, dehydration, weather (such as intense heat), and sensory stimuli, including bright lights or loud noises. Hypoglycemia, caused by skipping meals, is also a common trigger.

When a child begins exhibiting symptoms of migraine, parents should look at their lifestyle and make necessary adjustments to decrease the potential for an attack. This means ensuring the child is eating three square meals a day, getting a full night’s sleep, staying hydrated and minimizing stress. When a headache does occur, ibuprofen or acetaminophen can be used to help treat the pain.

Stress can be the most challenging trigger for children to manage. For many, the fear of getting a headache during school hours can exacerbate the situation. The Migraine Research Foundation says that migraine affects 39 million people in the United States, yet many people don’t understand how serious the condition can be.

When I was a young girl, my teachers would hand me Tylenol and send me back to my desk, where I would stay until the pain got so bad I had no choice but to beg to go home.

Gaitanis says this response is common, and also foolish.

“If somebody had sprained their knee or their ankle, we wouldn’t recommend that they keep running on it,” Gaitanis says. “You have to rest it; it’s not going to get better if you keep running on it. It’s not appropriate to tell a student they have to stay in class and tough it out.”

Leleszi encourages parents to work with their child’s teachers to come up with a plan. “There are asthma plans, there are seizure plans, there can be a plan for headache, too,” she says.

A plan could include having the child carry a water bottle throughout the day, eat healthy snacks between meals and have access to a place to rest when a headache strikes.

But what if lifestyle changes and over-the-counter medications don’t help? Leleszi says that’s when parents should talk to their pediatrician about taking the child to a specialist.

“I like to think that our pediatricians or family practitioners should have literacy for head pain and start the process,” she says. “If, however, the child is not getting relief, the medications aren’t working, things are worsening, and there are other worrisome pieces to that — missing school, missing extracurriculars — it’s time to consult pediatric neurology.”

Numerous prescription medications are available to children and adolescents, ranging from cyproheptadine, an antihistamine, to drugs such as Topamax and Elavil. Supplements, such as magnesium and riboflavin, have also been found to reduce the frequency and severity of migraine. All medications, though, come with side effects, and Leleszi warns that none of them will work if the patient isn’t doing all they can to avoid triggers.

“None of this works without the healthy habits,” she says. “I don’t care how much Elavil you use; if you’re not sleeping, forget it.”

I haven’t taken my own son to a neurologist yet. I’ve established clear rules around his sleeping and eating habits, and so far, it has helped lessen his attacks. But because of my history with the condition and the knowledge that migraine is often an inherited trait, I know there’s always a chance he’ll need more support as he gets older.

“[Migraine] is not a single entity with a single cause,” Gaitanis says. “Different patients will respond to different therapies. Your goal is to really identify for your individual patient what is going to work best for them. That takes a trial-and-error approach.”

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